Gallstones

Synonyms :  Biliary Calculus; Cholelith; Cholelithiasis, AND Cholecystitis
Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs,

Cholelithiasis (gallstone formation) is the commonest disorder of the biliary tree and it is unusual for the gallbladder to be diseased in the absence of gallstones. The condition affects about 20% of the population above 40 years of age. Gallstones are conveniently classified into cholesterol (made from cholesterol) or pigment stones (made from bilirubin with a variable degree of calcification). Cholesterol stones are the commonest type of gallstones encountered in developed countries (75%). 

Causes for gallstone formation:

       cholesterol gallstones occur when bile is supersaturated with cholesterol so it can crystallise, which can occur in different settings. Cholesterol is water insoluble and becomes water soluble by aggregation with bile salts and phospholipids such as lecithins, which are also found in bile. Risk factors for cholesterol stones are: increased age, female sex, increased parity, hormone replacement therapy, obesity, gastric surgery. The role of dietary cholesterol and hypercholesterolaemia is not certain, while high fat/low fibre diet and diabetes increase the risk. These stones are whitish/yellow, mainly round and greasy on the surface.

       pigment gallstones are formed when there is excess of unconjugated or conjugated bilirubin. Probably many factors can contribute to this situation such as infection in the biliary tree (through bacterial production of enzymes which can deconjugate bilirubin thus initiating precipitation and stone formation), haemolytic anaemia (increased production of bilirubin) and alcoholic cirrhosis (impaired conjugation of bilirubin). These stones are black, irregular, faceted or round, hard, almost like river pebbles, since they contain a substantial amount of calcium salts. 

Acute cholecystitis (inflammation of the gallbladder) is almost always associated with obstruction of the gallbladder neck or cystic duct by a gallstone. Reactive chemical inflammation of the gallbladder mucosa due to changes in chemical composition of bile follows eventually becoming bacterial in type (bacteria usually belong to normal gut flora). However, the exact pathogenesis of this transition is still not clear. Some patients have a chronic form of cholecystitis characterised by thick walled, fibrotic and contracted gallbladder, and presence of biliary sludge/stones in the lumen.

Clinical features:  < BACK TO TOP >

       Majority of gallstones are asymptomatic and remain so; only 20% sufferers develop clinical evidence of the disease.

       Gallstones eventually may present either as recurrent biliary pain caused by transient cystic duct obstruction or cholecystitis due to persistent cystic duct obstruction that hasn’t resolved.

       Biliary pain is located in the epigastrium or right upper abdominal quadrant, and radiates to the back to the interscapular region or the tip of the right scapula.

       The pain characteristically occurs after a fatty meal, progressively increasing to a plateau; it is sustained for about an hour and then subsiding gradually; overall duration of the pain is up to several hours.

       Nausea and vomiting often accompany the pain.

       Acute cholecystitis, together with more persistent pain (over 24 hours), usually presents with restlessness, pallor, sweating, nausea, vomiting, fever; fever is the most important distinguishing feature between uncomplicated biliary pain and cholecystitis.

       Tenderness in the right upper quadrant is usually noted, and jaundice can occur sometimes probably caused by oedema and obstruction of the common bile duct.

       A typical episode of acute cholecystitis improves in 2-3 days and disappears within 1 week; the most feared outcome is rupture of the gallbladder with spilling of purulent exudate (pus) into the abdominal cavity, leading to serious peritonitis.

       Differentiation between uncomplicated biliary pain and acute cholecystitis is often difficult on clinical ground.

Diagnosis:  < BACK TO TOP >

       Plain radiographs of the abdomen may show gallstones if they are radiopaque (cholesterol stones are not visible but bilirubin ones usually are due to their greater calcium component).

       Ultrasonography detects gallstones over 4mm in diameter and may show gallbladder thickening due to cholecystitis (oedema of the wall in acute and scarring in chronic cholecystitis).

       Cholecystography and cholescintigraphy show all types of gallstones as filling defects, but in cholecystitis the gallbladder usually can not be visualised due to cystic duct obstruction.

       Liver function tests are non-specific (variable increase in hepatic transaminases and alkaline phosphatase).

       Acute cholecystitis can be accompanied by leukocytosis and raised ESR.

Management  < BACK TO TOP >

       Asymptomatic gallstones found incidentally are not usually treated.

       Symptomatic gallstones are best treated surgically by means of cholecystectomy (removal of the gallbladder), preferably through a laparoscopic approach. Cholecystectomy relieves pain but for unknown reasons 50% of patients continue experiencing various digestive symptoms.

       Medical dissolution of cholesterol gallstones that are not calcified can be attempted using drugs based on bile acids such as ursodeoxycholic [Ursofalk] which increases the solubility of cholesterol. This is usually carried out in patients who decline surgery or when a surgery is associated with significant risk.

       Extracorporeal shock wave lithotripsy (ESWL) is a technique of gallstones fragmentation using shock waves (powerful vibrations) applied under water or on special table with a water-filled cushion. Fragments formed in this way can pass naturally through the biliary system or may dissolve and disappear spontaneously or on treatment.

       Management of acute cholecystitis consists of bed rest, relief of pain, antibiotics and maintenance of fluid balance. Surgical treatment is necessary (cholecystectomy by either laparotomy or laparoscopy) but it is usually done later (elective surgery).

       In some centres the surgery is attempted in acute episode of cholecystitis avoiding two hospitalisations and reducing costs, but such surgery can be more risky than the postponed one (e.g., rupture of acutely inflamed gallbladder with secondary peritonitis).

Prognosis  < BACK TO TOP >

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Nutrition < BACK TO TOP >

Nutrition that alleviate or prevent Gallstones :-
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Herbs < BACK TO TOP >

Herbs that alleviate or prevent Gallstones :-
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